10 1111@dth 12035

Dermatologic Therapy, Vol.
27, 2014, 2123

Printed in the United States All rights reserved
2013 Wiley Periodicals, Inc.
DERMATOLOGIC THERAPY
ISSN 1396-0296
THERAPEUTIC HOTLINE
Efficacy of treatment with oral
alitretinoin in patient suffering from
lichen simplex chronicus and severe
atopic dermatitis of hands
Angelo Massimiliano DErme*, Nicola Milanesi*,
Arianna Fay Agnoletti, Vincenza Maio, Daniela Massi &
Massimo Gola*
*Allergological and Occupational Dermatology Unit, Department of Surgery
and Translational Medicine, University of Florence, Florence, DISSAL
Section of Dermatology San Martino-IRCCS, Genoa, and Division of
Pathological Anatomy, Department of Critical Care Medicine and Surgery,
University of Florence, Florence, Italy
ABSTRACT: Lichen simplex chronicus (LSC) is a skin disorder characterized by chronic itching and
scratching, which can lead to thick, leathery, brownish skin, sometimes with papules and can be
associated with atopic eczema. We report the case of a 52-year-old man with a 45-year atopic condition
and presenting LSC in his dorsum. After a 3-month treatment with alitretinoin at the daily dosage of
30 mg, we have observed a moderate improvement of the hand eczema together with a substantial
clinical improvement of LSC and an almost complete resolution of pruritus. We want to report this
peculiar case to suggest the use of oral alitretinoin for LSC.
KEYWORDS: alitretinoin, atopic dermatitis, lichen simplex chronicus
Address correspondence and reprint requests to: Angelo

Massimiliano DErme, MD, Allergological and Occupational
Dermatology Unit, Department of Surgery and Translational
Medicine, University of Florence, Piazza dellIndipendenza 11,
50129 Florence, Italy, or email: [email protected].
Learning Points: Alitretinoin can represent an effective drug
for the treatment of lichen simplex chronicus and atopic
dermatitis of hands.
The authors declare no affiliation or significant financial
involvement in any organization or entity with a direct
financial interest in the subject matter or materials discussed
in the following manuscript.
Introduction
Lichen simplex chronicus (LSC) is a skin disorder
characterized by chronic itching and scratching, which can lead to thick, leathery, brownish
skin, sometimes with papules and can be associated with atopic eczema. Standard therapeutic options include topical corticosteroids,
calcineurin inhibitors, phototherapy, retinoids,
psychopharmacological agents, systemic corticosteroids, and other immunomodulatory agents
21
DErme et al.
such as cyclosporin A and combinations thereof

(1).
Alitretinoin (9-cis-retinoic acid) is a novel
endogenously occurring vitamin A derivative,
which binds both retinoic acid receptors and retinoid X receptors. It has recently been licensed in
Italy for oral treatment of severe chronic hand
eczema (CHE) unresponsive to potent topical corticosteroids (2,3).
In the literature, only one case has been
described reporting the efficacy of alitretinoin in
extrapalmar atopic eczema (4). The authors
reported the successful oral alitretinoin treatment
of six patients suffering from diffuse atopic eczema
associated with atopic CHE lesions, whereas no
reports are available regarding its potential use in
atopic eczema.
Report
We report the case of a 52-year-old man with a
45-year history of atopy and atopic eczema.
At the first medical examination, he presented
with chronic and severe hand eczema and erythematous and scratched nonconfluent papules involving the dorsum (between shoulders
and the neck area) (FIG. 1A). He referred severe
pruritus.
These lesions had been present for more than a

year and had become permanent. The previous
year, the patient had carried out a cycle of 12 narrowband UVB sessions, which he had to stop
because he did not tolerate the treatment.
Moreover, he resulted unresponsive to potent
topical corticosteroids both on hands and on the
dorsum.
During the first visit, the patient underwent
allergological examination and cutaneous biopsy
of a lesion on the dorsum.
The skin prick test with common allergens
revealed positive atopy markers to pollen and dermatophagoides pteronyssinus. Patch tests were
carried out according to International Contact Dermatitis Research Group (ICDRG) recommendations with standard and additional allergens. At
Day 4, the patient showed no reaction to the
allergens of standard SIDAPA (Italian Society of
Allergological, Occupational and Environmental
Dermatology) series.
Histopathological examination showed a
spongiotic dermatitis associated to a sparse
superficial dermal inflammatory infiltrate with
lymphocytes, rare eosinophils, and melanophages
(FIG. 1B).
These findings led to the diagnosis of LSC of the
dorsum in patient suffering from atopic dermatitis
of the hands.
FIG. 1. (A) Chronic and severe hand eczema with erythematous and scratched nonconfluent papules on the dorsum. (B) Hyperorthokeratosis, parakeratosis, acanthosis, spongiosis, and a dermal lymphohistiocytic infiltrate with some eosinophils and melanophages (EE 20). (C) Substantial clinical improvement of lichen simplex chronicus after 3 months of therapy with oral
alitretinoin. Resolution of papules and erythema of the dorsum.
22
Alitretinoin in lichen simplex chronicus
The patient was treated for CHE with oral alitretinoin at the daily dosage of 30 mg for 12 weeks and
with emollients as a basic topical therapy.
After 3 months of treatment, a moderate
improvement of the hand eczema was observed
together with a substantial clinical improvement
of LSC (FIG. 1C). After 4 months from the end
of treatment, no recurrence of lesions has been
observed.
The clinical improvement was followed by an
almost complete resolution of pruritus. In fact,
the patients visual analogue scales (VAS) itch
decreased from 80 at the baseline to 10 at the end of
the treatment. The therapy was generally well tolerated; no cutaneous or systemic side effects were
observed.
was paralleled by a marked reduction of pruritus,

rubbing, and scratching, which had a positive
impact on quality of life and contributed to skin
lesion improvement.
Our case suggests that oral alitretinoin may constitute a novel, effective, and well-tolerated treatment option for exacerbated LSC refractory to
standard topical treatments.
In conclusion, our case, together with the six
cases described by Grahovac et al. (4), suggests a
potential benefit of oral alitretinoin treatment of
LSC as a manifestation of extrapalmar atopic
eczema.
However, further analysis with longer follow-ups
and randomized controlled trials are needed to
confirm our clinical observation.
References
Discussion
No studies or cases have been published so far
regarding the potential benefits of this drug in LSC.
Alitretinoin is the only retinoid that activates
both intracellular retinoid acid receptors, retinoic
acid receptors and retinoid X receptors. It is
known to have immunomodulating and antiinflammatory effects and a regulating action on the
keratinocyte cytokine production and leukocyte
activity. In our patient, the clinical improvement
1. Lotti T, Buggiani G, Prignano F. Prurigo nodularis and lichen

simplex chronicus. Dermatol Ther 2008: 21 (1): 4246.
2. Ruzicka T, Lynde CW, Jemec GB, et al. Efficacy and safety of
oral alitretinoin (9-cis retinoic acid) in patients with severe
chronic hand eczema refractory to topical corticosteroids:
results of a randomized, double-blind, placebo-controlled,
multicentre trial. Br J Dermatol 2008: 158 (4): 808817.
3. Bissonnette R, Worm M, Gerlach B, et al. Successful retreatment with alitretinoin in patients with relapsed chronic hand
eczema. Br J Dermatol 2010: 162 (2): 420426.
4. Grahovac M, Molin S, Prinz JC, Ruzicka T, Wollenberg A.
Treatment of atopic eczema with oral alitretinoin. Br J Dermatol 2010: 162 (1): 217218.
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Dermatologic Therapy, Vol.

27, 2014, 2123

2013 Wiley Periodicals, Inc.

Address correspondence and reprint requests to: Angelo

such as cyclosporin A and combinations thereof

These lesions had been present for more than a

Alitretinoin in lichen simplex chronicus

was paralleled by a marked reduction of pruritus,

1. Lotti T, Buggiani G, Prignano F. Prurigo nodularis and lichen

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